Provider Demographics
NPI:1194943522
Name:BERRY, PHILIP TODD (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:TODD
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 615A
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-9784
Mailing Address - Country:US
Mailing Address - Phone:304-388-2525
Mailing Address - Fax:304-388-2537
Practice Address - Street 1:RR 2 BOX 615A
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917-9784
Practice Address - Country:US
Practice Address - Phone:304-388-2525
Practice Address - Fax:304-388-2537
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2120207Q00000X
OH34.012389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181970Medicaid
WV3810010455Medicaid
WV3810010455Medicaid
WV2029584Medicare PIN
WV2029583Medicare PIN
WV2029581Medicare PIN